- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.00 / $204.50 / $513.36
| Facility | | $182.00 | $204.50 | $513.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.68 / $312.89 / $347.32
| Professional | | $272.68 | $312.89 | $347.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.33 / $235.33 / $235.33
| Facility | | $235.33 | $235.33 | $235.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Facility | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $307.55
| Professional | | $307.55 | $307.55 | $307.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.60 / $310.30 / $334.54
| Professional | | $274.60 | $310.30 | $334.54 |